1. Urology Cancer Update for Primary Care 29 June 2019
Greater Manchester Cancer
Suspected Prostate Cancer Best Timed Pathway (BTP) Susan Todd Project Manager
Urology Cancer Update for Primary Care
29 June 2019

2. NHSE Prostate BTP
Greater Manchester Cancer

3. Greater Manchester Cancer
NHSE Prostate BTP

4. Greater Manchester Cancer
Patient Information

5. Greater Manchester Cancer
Prostate BTP
1. Locally mandated information is determined with commissioners but should include demographics, investigation results (PSA, U&E/ eGFR, urine dipstick (+ MSU result if dipstick positive), and DRE), performance status, weight and BMI, medication, anti-coagulant history, and MRI scanning exclusion criteria. A PSA of >3ng/ml should be used as referral rate for men aged A rectal swab may also be required.

6. Suspected Cancer Referral
Greater Manchester Cancer
Suspected Cancer Referral

7. Suspected Cancer Referral - eGFR
Greater Manchester Cancer
Suspected Cancer Referral - eGFR

8. Greater Manchester Cancer
Q. Why is eGFR required? A. Because the multi-parametric MRI includes contrast enhanced sequences
ESUR/RCR guidelines
Advise caution in patients with eGFR <30 ml/min
Main risk of Gadolinium-based contrast agents is nephrogenic systemic fibrosis (NSF)
Develops from day of exposure to 2/3 months
Early changes: pain, pruritis, swelling and erythema usually starting in legs, can progress to fibrosis and limb contractures, fibrosis of internal organs, death
Incidence in severe renal failure (eGFR <15ml/min) is 0.1-1%

9. Greater Manchester Cancer
In many cases the DCE adds significant confidence - the ADC is grainy and difficult to interpret T2
B 1000
ADC
DCE
This is a case with a large anterior lesion and is relatively clear to see – but the ADC has signal dropout – and if this lesion had been smaller and more difficult to see the DCE is extremely useful to clarify - and now MR is used to make significant front end decisions for patients, including NO BIOPSY - absolutely need highest quality imaging. Helps to avoid missing small but significant tumours. Because of T2 shine thro on DW b value images, need ADC to confirm real impeded diffusion, as DWI based on T2 sequences.

10. Prostate BTP: eGFR Greater Manchester Cancer
Optimal MRI scan (mpMRI) within 7 days, the eGFR needs to be known before the scan date
Consider the U&E box when requesting PSA blood test (before decision to refer for suspected cancer)
No eGFR, no DCE, no scan, delay to patient
Patient can have the contrast agent (if eGFR more than 30ml/min)
DCE:
Greater confidence cancer/no cancer
numbers patients having prostate biopsy
Some patients informed swiftly of no cancer

11. Greater Manchester Cancer
Telephone Triage

12. Patient information sheet: susan.todd7@nhs.net
Greater Manchester Cancer
Referral forms: Dr Sarah Taylor, Primary Care GM Cancer Lead and Macmillan GP,
Patient information sheet:
NHSE Prostate pathway:
GatewayC